D. Kirsch

Changes in the extracellular matrix of the vein wall : The cause of primary varicosis?

BACKGROUND Conflicting theories on the development of primary varicosis have led to the molecular biological investigation of the vein wall or, more accurately, of the extracellular matrix. It was the aim of this study to quantify matrix expression and to compare pathological changes in the vein wall with valve-orientated staging of varicosis, in order to determine indicators of the primary cause of varicosis. MATERIALS AND METHODS Three hundred seventy-two tissue specimens of greater saphenous veins were obtained from 17 patients with varicosities and categorised according to Hach stage and procurement site. The specimens were compared with 36 specimens collected from six patients without varicosities, incubated with fluorescence-stained antibodies for collagen 4, laminin, fibronectin and tenascin prior to being assessed with confocal laser scan microscopy. In addition, 22 vein specimens (16 varicose, 6 normal veins) serving as negative controls were investigated. RESULTS Image analysis and statistical evaluation showed that compared with normal veins, varicose veins are associated with a significant increase in matrix protein expression for collagen 4, laminin and tenascin. A trend towards an increase in matrix expression was further observed for fibronectin. There was, however, no difference between varicose veins and clinically healthy vein segments inferior to a varicose segment. CONCLUSION If the findings of the present investigation can be confirmed by other studies, alterations in the vein wall may be regarded as the primary cause of varicosis and valvular insufficiency as the result of these changes.

Alterations of the extracellular matrix of venous walls in varicous veins

Background: Investigation of changes in normal veins which result in the formation of varicosis led to examination of the histological organisation of the vessel wall and to histomorphological alte...BACKGROUND Investigation of changes in normal veins which result in the formation of varicosis led to examination of the histological organisation of the vessel wall and to histomorphological alterations in the region of the extracellular matrix. PATIENTS AND METHODS The expression pattern of the matrix proteins collagen IV, fibronectin, laminin, tenascin, and undulin as well as the structure and orientation of elastic fibres were determined by means of immunohistochemical staining. RESULTS All varices exhibited an increased expression pattern in comparison to healthy veins. The venous vessel wall was often non-homogeneously enlarged. The intima was always more involved than the media and showed enhanced accumulation, whereas, the adventitia was not influenced by the pathological process. Collagen IV exhibited an early accumulation, especially in the subendothelial region. The other matrix proteins demonstrated an increase in fibre propagation parallel to the enlargement of the vessel wall. Essentially, an augmented de novo synthesis of fibres with an irregular arrangement and the formation of local plaques was found. Elastic fibres were enhanced by slight involvement of the vessel wall and were reduced and fragmented during increased involvement of the venous wall which explained the rigidity of varices in contrast to normal veins.

Primäre Varicosis – Veränderungen in der Venenwand und im elastischen Verhalten

Abstract. The aetiology of varicosis is still unclear. Investigation of changes in normal veins which result in the formation of varicosis led to examination of elastic properties and histomorphological alterations in the region of the extracellular matrix in the vessel wall of the long saphenous vein in normal and varicose veins. The rigidity of varicose veins was higher than that of normal veins; there was no difference between the varicose vein above a competent valve and the „normal“ vein below this competent valve. The matrix proteins demonstrated an increase in total fibres, whereas the elastic fibres were reduced and fragmented, explained the rigidity of varices. These results suggest that the role of the venous valves in the development of varicose veins is secondary to changes of the vein wall.Zusammenfassung. Die Frage nach der Pathogenese der Varicen führte zu Untersuchungen varicöser V. saphena magna im Vergleich mit klinisch noch gesunder Vene und klinisch und histologisch gesunder Vene. Untersucht wurde das mechanische Verhalten und die extracelluläre Matrix. Es zeigte sich, daß die Varicenwand rigider war als die Wand normaler Venen, davon war auch die Venenwand unterhalb einer noch intakten Venenklappe betroffen. Die Veränderung der Vene und damit die Ursache für die Änderung der Zugfestigkeit lag in der Venenwand und hier insbesondere an den Bestandteilen der extracellulären Matrix. Die Matrixproteine lagen vermehrt vor, die elastischen Fasern waren reduziert und fragmentiert. In der Zusammenschau der mechanischen Versuche und der immunhistochemischen Ergebnisse läßt sich die Theorie der primären Klappenzerstörung und der anschließenden varicösen Umbildung der Vene nicht bestätigen, viel eher kommt es zunächst zu einer Veränderung der Venenwand und damit auch zu einer Klappeninsuffizienz.

Die aortoduodenale fistel

Six patients were operated on for an aortoduodenal fistula at the Department of General and Abdominal Surgery, Johannes-Gutenberg-University Mainz. All patients had received an aortic graft implant between 1 and 10 years ago. The etiology, symptoms, and diagnostic and surgical treatment of these six cases are presented, and the results are discussed in comparison with the results of other studies. The main symptom of all of our patients was gastrointestinal bleeding. In our patients arteriography and computed tomography were the best diagnostic procedures. At surgery, five patients underwent graft excision and axillobifemoral bypass (only four patients, as one died before implantation). In the other patient a local repair, with closure of the graft defect and bowel defect, followed by interposition of an omental pedicle, was performed. Two patients died within 6 days of operation due to multiple organ failure.ZusammenfassungAn der Klinik und Poliklinik für Allgemein-und Abdominalchirurgie der Johannes-Gutenberg-Universität Mainz wurden zwischen 1984 und Februar 1992 6 Patienten wegen einer aortoduodenalen Fistel operiert. Anamnese, Symptome, Diagnostik und operative Behandlung dieser Patienten werden anhand anderer Studienergebnisse analysiert und dargestellt. Bei allen Kranken wurde zwischen einem und 10 Jahren vor Auftreten der aortoduodenalen Fistel eine Aortenprothese implantiert. Führendes Symptom war die gastrointestinale Blutung. Die Angiographie und die Computertomographie waren in unserem Krankengut die Methoden mit der größten Treffsicherheit. Bei 5 Patienten wurde die infizierte Prothese explantiert, 4 dieser 5 Patienten erhiel ten anschließend einen axillobifemoralen Bypass, em Kranker starb vor der Rekonstruktion. Die Direktnaht der Aorta und Verschluß der Darmläsion mit anschlieBender Netzinterposition wurde bei einem weiteren Patienten durchgeführt. Zwei Kranke, unter Notfallbedingungen im Volumenmangelschock operiert, starben innerhalb der ersten 6 postoperativen Tage. Die anderen Patienten überlebten einen Zeitraum von mindestens einem Viertel bis zu einem Jahr.Six patients were operated on for an aortoduodenal fistula at the Department of General and Abdominal Surgery, Johannes-Gutenberg-University Mainz. All patients had received an aortic graft implant between 1 and 10 years ago. The etiology, symptoms, and diagnostic and surgical treatment of these six cases are presented, and the results are discussed in comparison with the results of other studies. The main symptom of all of our patients was gastrointestinal bleeding. In our patients arteriography and computed tomography were the best diagnostic procedures. At surgery, five patients underwent graft excision and axillobifemoral bypass (only four patients, as one died before implantation). In the other patient a local repair, with closure of the graft defect and bowel defect, followed by interposition of an omental pedicle, was performed. Two patients died within 6 days of operation due to multiple organ failure.

Endovaskuläre Aneurysmatherapie – Langzeitergebnisse nach 7 Jahren

ZusammenfassungHintergrund: Seit der Entwicklung von Stentprothesen und deren kommerzieller Verfügbarkeit 1994 gibt es eine neue, sich zunehmend verbreitende endovaskuläre Methode der Aneurysmatherapie. Patienten und Methodik: In 7 Jahren, von 1994–2001, erhielten 115 Patienten mit Bauchaortenaneurysma (AAA) an unserer Institution gemeinsam durch Radiologen und Gefäßchirurgen eine endovaskuläre Aneurysmaausschaltung mit Stentor®-, Vanguard®- und Talent®-Stentprothesen. Es wurden überwiegend modulare Bifurkationsprothesen in Lokalanästhesie und nach präoperativer Embolisierung der Arteria mesenterica inferior und der Lumbalarterien eingesetzt. Ergebnisse: Stentprothesen der ersten und zweiten Generation weisen eine sehr hohe Spätkomplikationsrate von insgesamt 52% auf. Bei 30% mussten radiologisch-interventionelle oder chirurgische Maßnahmen zur Erhaltung des Ziels, der Aneurysmaausschaltung getroffen werden. In weiteren 22% besteht in der Nachbeobachtung ein Endoleak oder eine Migration von Prothesen, durch die ein Endoleak droht. Stentprothesen der dritten Generation haben eine niedrigere Spätkomplikationsrate mit Interventionen in 12,2% und Endoleaks sowie Konfigurationsänderungen der Stentprothesen in 18,3%, entsprechend einer Gesamtkomplikationsrate von 30,5%. Schlussfolgerung: Angesichts der hohen Kosten, der ständigen Kontrollbedürftigkeit wegen der ungewissen Lebensdauer der Implantate und der damit verbundenen hohen Spätkomplikationsrate ist die endovaskuläre Methode der konventionellen Operation noch nicht als ebenbürtig anzusehen und sollte individuell indiziert werden.AbstractBackground: Stentgrafts for endovascular treatment of abdominal aortic aneurysms (AAA) have been commercially available since 1994, with now large numbers of implantations all over the world. Patients and Methods: From 1994–2001, 115 patients were treated with Stentor®, Vanguard® and Talent® stentgrafts in our institution. Results: Late complications of the first- and second-generation stentgrafts as radiologic or surgical interventions to maintain complete exclusion of the aneurysm amounted to 30% with an additional 22% for observed endoleaks and configuration changes of the stentgraft. Third-generation stentgrafts had a lower complication rate of 12.2% for interventions and 18.3% for late endoleaks and graft changes. Conclusion: High costs of the devices, a pretty high late complication rate, and the uncertain maintenance of stentgraft function to prevent aneurysm rupture currently limit the widespread application of this new technology, leaving conventional aneurysmectomy the standard for aneurysm treatment and reserving the endovascular method for selected patients.

Veränderungen der extrazellulären Matrix in der Venenwand – Ursache der primären Varikosis?

Background: Conflicting theories on the development of primary varicosis have led to the molecular biological investigation of the vein wall or, more accurately, of the extracellular matrix. It was the aim of this study to quantify matrix expression and to compare pathological changes in the vein wall with valve-orientated staging of varicosis, in order to determine indicators of the primary cause of varicosis. Materials and methods: Three hundred seventy-two tissue specimens of greater saphenous veins were obtained from 17 patients with varicosities and categorised according to Hach stage and procurement site. The specimens were compared with 36 specimens collected from six patients without varicosities, incubated with fluorescence-stained antibodies for collagen 4, laminin, fibronectin and tenascin prior to being assessed with confocal laser scan microscopy. In addition, 22 vein specimens (16 varicose, 6 normal veins) serving as negative controls were investigated. Results: Image analysis and statistica...

Evaluation und interne Qualitätssicherung in der Allgemein- und Abdominalchirurgie

The measuring of perioperative risk, the finding of intraoperative influences and the objective rating of quality of treatment were achieved by our program of quality assurance. With our system it is possible to measure differences between several surgeons and also differences in comparison to national and international results. Through optimised therapy the program can lead to an improvement of quality.

Langzeitergebnisse nach rekonstruktiven Eingriffen im aortoiliakalen Abschnitt

From September 1985 to February 1994, 183 patients (arterial occlusive diseasen=108, abdominal aneurysmn=75) underwent reconstruction of the abdominal aorta. In 120 patients an aorto-bi-iliac or aorto-bi-femoral reconstruction was performed and in 63 patients a tubetype reconstruction. The early and late postoperative complications are described. The complications were dependent on the choice of graft, the distal anastomosis and the preoperative risk factors. The mortality from elective repairs was compared with the mortality in emergency repairs. The role of endovascular reconstructive surgery in comparison to conventional reconstructive procedures is discussed.ZusammenfassungIm Zeitraum von September 1985 bis Februar 1994 wurde bei 183 Patienten ein rekonstruktiver Eingriff im aortoiliakalen Bereich durchgeführt. Die Grunderkrankung war in 108 Fällen eine arterielle Verschlußkrankheit, in 75 Fällen ein abdominales Aortenaneurysma. Bei 120 Patienten wurde eine Bifurkationsprothese, bei 63 Patienten eine Rohrprothese implantiert. Die Früh- und Spätkomplikationen werden beschrieben, differenziert nach chirurgisch und nichtchirurgisch, wobei die chirurgischen Komplikationen im wesentlichen durch die Prothesenart und durch den Leistenanschluß bedingt waren, während die nichtchirurgischen Komplikationen vom Risikoprofil des Krankenguts abhängig waren. Die Unterschiede in der postoperativen Letalität ergaben sich durch die Dringlichkeit des Eingriffs. Der Stellenwert der endovaskulären Rekonstruktion im Vergleich zur rekonstruktiven Gefäßchirurgie wird diskutiert.